TL;DR
As an FCA-authorised broker that has helped arrange over 900,000 policies, WeCovr knows that understanding what private medical insurance in the UK doesn't cover is as crucial as knowing what it does. This guide demystifies the common exclusions to help you choose your policy with confidence. WeCovr's guide to common exclusions and how to avoid surprises when claiming Private Medical Insurance (PMI) is a fantastic tool for managing your health.
Key takeaways
- Sarah develops sudden, sharp abdominal pain. Her GP suspects appendicitis. Her PMI provider authorises a private consultation with a surgeon and the subsequent operation to remove her appendix. This is an acute condition, and it's covered.
- David has been managing his Type 2 diabetes for several years with medication and regular GP check-ups. He cannot use his PMI to pay for his insulin, blood sugar test strips, or routine appointments with the diabetes nurse. This is a chronic condition and is excluded.
- Moratorium Underwriting: This is the most common and straightforward option. Your insurer won't ask for your full medical history upfront. Instead, they apply a "waiting period" (usually 24 months). If you go for two continuous years without any symptoms, treatment, medication, or advice for a pre-existing condition, it may become eligible for cover.
- Full Medical Underwriting (FMU): You provide your full medical history via a detailed questionnaire when you apply. The insurer assesses your health background and explicitly lists any conditions that will be permanently excluded from your policy. It's more work initially but provides absolute clarity from day one.
- Diabetes (Type 1 and Type 2)
As an FCA-authorised broker that has helped arrange over 900,000 policies, WeCovr knows that understanding what private medical insurance in the UK doesn't cover is as crucial as knowing what it does. This guide demystifies the common exclusions to help you choose your policy with confidence.
WeCovr's guide to common exclusions and how to avoid surprises when claiming
Private Medical Insurance (PMI) is a fantastic tool for managing your health. It offers prompt access to specialist consultations, diagnostic tests, and high-quality private treatment, allowing you to bypass long NHS waiting lists. In mid-2025, the NHS waiting list in England remained stubbornly high, with over 7.5 million treatment pathways involving millions of individual patients, highlighting the value of having a private alternative.
However, PMI is not an all-access pass to any and every medical procedure. It's a specific type of insurance designed for a particular purpose. Understanding its boundaries is the key to a smooth and successful claims experience. Misconceptions about what's covered can lead to disappointment and unexpected bills.
This comprehensive 2026 guide will walk you through everything that is typically excluded from a standard UK private health insurance policy, explain the nuances, and give you the knowledge to navigate your cover like a pro.
The Golden Rule of UK Private Health Insurance: Acute vs. Chronic
If you remember only one thing from this guide, let it be this: Standard UK private medical insurance is designed to cover the treatment of new, short-term, curable medical conditions that arise after you take out your policy.
These are known as acute conditions.
In contrast, PMI does not cover chronic conditions or pre-existing conditions. This is the single most important distinction to grasp.
| Condition Type | Definition | Is it Covered by Standard PMI? | Example |
|---|---|---|---|
| Acute Condition | A disease or illness that comes on suddenly, is short-term, and is likely to respond quickly to treatment, leading to a full recovery. | ✅ Yes | A broken arm, a cataract, appendicitis, a hernia requiring surgery. |
| Chronic Condition | A long-term condition that cannot be cured but can be managed through medication, therapy, and check-ups. | ❌ No | Diabetes, asthma, high blood pressure, arthritis, Crohn's disease. |
| Pre-existing Condition | Any illness, disease, or injury for which you have had symptoms, medication, advice, or treatment before your policy start date. | ❌ No (with some exceptions after a set period) | Asthma you were diagnosed with five years ago; knee pain you saw a GP about last year. |
Real-Life Example:
- Sarah develops sudden, sharp abdominal pain. Her GP suspects appendicitis. Her PMI provider authorises a private consultation with a surgeon and the subsequent operation to remove her appendix. This is an acute condition, and it's covered.
- David has been managing his Type 2 diabetes for several years with medication and regular GP check-ups. He cannot use his PMI to pay for his insulin, blood sugar test strips, or routine appointments with the diabetes nurse. This is a chronic condition and is excluded.
What Are Standard PMI Exclusions in 2026? A Detailed Breakdown
Beyond the fundamental rule of acute vs. chronic, every policy has a list of specific general exclusions. While the exact wording can vary between insurers like Bupa, AXA Health, Aviva, and Vitality, these are the items you will almost certainly find are not covered by a standard UK policy.
1. Pre-existing Conditions
This is the bedrock of all PMI exclusions. Insurers will not cover you for medical conditions you already have when you join. How they apply this rule depends on the type of underwriting you choose.
- Moratorium Underwriting: This is the most common and straightforward option. Your insurer won't ask for your full medical history upfront. Instead, they apply a "waiting period" (usually 24 months). If you go for two continuous years without any symptoms, treatment, medication, or advice for a pre-existing condition, it may become eligible for cover.
- Full Medical Underwriting (FMU): You provide your full medical history via a detailed questionnaire when you apply. The insurer assesses your health background and explicitly lists any conditions that will be permanently excluded from your policy. It's more work initially but provides absolute clarity from day one.
As expert PMI brokers, WeCovr can help you understand which underwriting method is best for your personal circumstances.
2. Chronic Conditions
As explained, the ongoing management of long-term illnesses is not covered. Your policy is there to get you diagnosed and restore you to your previous state of health, not to provide day-to-day management of an incurable condition.
Common Chronic Conditions Excluded from PMI:
- Diabetes (Type 1 and Type 2)
- Asthma
- High Blood Pressure (Hypertension)
- Arthritis (all forms, including rheumatoid and osteoarthritis)
- Multiple Sclerosis (MS)
- Crohn's Disease and Ulcerative Colitis
- Eczema and Psoriasis
- Chronic Obstructive Pulmonary Disease (COPD)
Important Note: A PMI policy may cover the initial diagnostic tests to determine if you have a chronic condition. For example, if you develop symptoms, your policy might cover the consultations and scans that lead to a diagnosis of arthritis. However, once the condition is diagnosed as chronic, its future management will be excluded and fall back to the NHS or self-funding.
3. Emergency Services (A&E)
Private health insurance is not a replacement for emergency services. If you have a heart attack, a stroke, or are involved in a serious accident, you must call 999 and go to an NHS A&E department. Private hospitals are not equipped to handle major trauma or life-threatening emergencies.
PMI is for planned, non-emergency treatment (known as elective treatment) and diagnostics.
4. Normal Pregnancy and Childbirth
Standard private health cover does not include routine antenatal care, delivery, or postnatal check-ups. The NHS provides excellent maternity services, and this is considered a lifestyle event rather than an unforeseen illness.
However, some more comprehensive and expensive policies may offer cover for complications that arise during pregnancy or childbirth. This is always an added-extra and will be clearly stated in the policy benefits.
5. Cosmetic and Aesthetic Surgery
Any treatment that is purely for cosmetic reasons is excluded. This includes procedures like:
- Rhinoplasty (nose jobs)
- Breast augmentation
- Liposuction
- Facelifts
- Botox and fillers
The key distinction is whether the treatment is medically necessary. For example, reconstructive surgery following an accident or a mastectomy after cancer treatment is often covered, as it aims to restore function or a normal appearance.
6. Mental Health Conditions (On Basic Plans)
This is a significant area of variation. Historically, mental health was a common exclusion. Today, the market is much more nuanced.
- Basic Policies: Often have very limited or no cover for mental health.
- Mid-Range & Comprehensive Policies: Increasingly offer excellent mental health support. This can include cover for talking therapies (like CBT), psychiatric consultations, and even in-patient treatment for a limited period.
According to the Office for National Statistics (ONS), around 1 in 5 adults experienced some form of depression in early 2021. Insurers have recognised this need, but you must check the specific level of mental health cover on your chosen plan. It's one of the most important factors to compare.
7. Self-inflicted Injuries & High-Risk Activities
Insurers will not cover treatment for injuries or illnesses resulting from:
- Drug or alcohol abuse
- Suicide attempts or intentional self-harm
- Participation in professional sports
- Engaging in hazardous sports or hobbies (e.g., motor racing, mountaineering, kitesurfing), unless you have declared them and paid an additional premium.
8. Specific Treatments and Aids
Certain treatments and services are generally handled by the NHS or are considered part of social care, and are therefore excluded:
- Kidney Dialysis: This is a long-term treatment for a chronic condition.
- Organ Transplants: These are highly complex and expensive procedures managed through a national NHS programme.
- Mobility Aids: Items like wheelchairs, walking frames, or hearing aids are typically not covered.
9. Infertility Treatment
The investigation and treatment of infertility, including procedures like IVF (In-vitro Fertilisation), are almost always excluded from standard PMI policies.
10. Experimental or Unproven Treatments
Private insurers will only fund treatments and drugs that are evidence-based and approved by official bodies like the National Institute for Health and Care Excellence (NICE). Any treatment considered experimental, unproven, or not yet licensed in the UK will be excluded.
Understanding Underwriting: Moratorium vs. Full Medical Underwriting (FMU)
Choosing your underwriting type is one of the first decisions you'll make. It directly impacts how your pre-existing conditions are handled.
| Feature | Moratorium Underwriting | Full Medical Underwriting (FMU) |
|---|---|---|
| Upfront Process | Quick and simple. No medical questionnaire. | Requires a detailed medical questionnaire. Insurer may contact your GP. |
| Clarity on Cover | Less clear at the start. You may not know if a condition is covered until you claim. | Crystal clear from day one. You receive a policy certificate listing all specific exclusions. |
| Cover for Pre-existing Conditions | A condition may become eligible for cover after a 2-year period free of symptoms, treatment, or advice. | Exclusions are typically permanent. What's excluded at the start remains excluded. |
| Claims Process | Can be slower, as the insurer will investigate your medical history at the point of claim. | Generally faster, as the insurer already knows what is and isn't covered. |
| Best For... | People with a clean bill of health or minor past issues who want a quick start. | People with a complex medical history who want absolute certainty about their cover. |
Which one is right for you? Talking to an independent PMI broker like WeCovr is invaluable here. We can assess your health history and goals to recommend the most suitable and cost-effective underwriting option, at no extra cost to you.
The "Grey Areas": What Might Be Covered Depending on Your Policy?
Not everything is black and white. Many benefits are excluded from basic policies but can be included as standard on comprehensive plans or added for an extra premium. This is where comparing policies is vital.
Cancer Care
Virtually all UK PMI policies offer some level of cancer cover, as it's a primary reason people buy insurance. However, the depth of this cover varies significantly.
- Standard Cover: Includes diagnosis, surgery, chemotherapy, and radiotherapy.
- Comprehensive Cover: May include access to drugs not yet available on the NHS, specialist therapies, stem cell treatment, and extensive aftercare support.
Given that 1 in 2 people in the UK will develop some form of cancer during their lifetime, according to Cancer Research UK, scrutinising the level of cancer cover is essential.
Therapies (Physiotherapy, Osteopathy, Chiropractic)
Most policies include cover for therapies to treat acute conditions, like a sports injury. The main difference is the limit. A basic plan might offer £500 of cover or 6 sessions, whereas a top-tier plan may offer unlimited sessions as long as they are medically justified. (illustrative estimate)
Dental and Optical Cover
Routine dental check-ups, fillings, eye tests, and glasses are not covered by standard PMI. They are usually offered as optional add-ons for an extra monthly fee. This add-on typically covers a portion of your costs for routine care and a larger amount for dental emergencies or major restorative work.
Wellness and Preventative Health
Traditionally, insurance only paid out when you were sick. Modern PMI providers are increasingly adding preventative benefits to help you stay healthy. These can include:
- Discounted gym memberships
- Health screenings and assessments
- Stop smoking programmes
- Access to wellness apps
These benefits are designed to add day-to-day value to your policy and can help reduce your long-term health risks.
How to Avoid Surprises: A Pre-Claim Checklist
The best way to ensure a smooth claim is to be prepared. Follow this simple checklist.
- Read Your Policy Documents: Before and after you buy, read the Insurance Product Information Document (IPID) and the full policy wording. These legally required documents summarise exactly what is and isn't covered.
- Be 100% Honest on Your Application: Withholding information about your medical history (non-disclosure) is a serious issue. If an insurer discovers you weren't truthful, they can cancel your policy and refuse to pay any claims, even those unrelated to the non-disclosed condition.
- Always Get Pre-Authorisation: This is a non-negotiable step. Before you see a specialist or book any treatment, you must call your insurer. They will confirm if the condition and proposed treatment are covered under your plan and provide you with a pre-authorisation number. Without this, your claim will be rejected.
- Understand Your Excess: Your policy excess is the amount you agree to pay towards the cost of any claim. For example, if you have a £250 excess and your treatment costs £3,000, you pay the first £250 and the insurer pays the remaining £2,750. Choosing a higher excess can lower your premium.
- Check Your Hospital List: Policies come with different tiers of hospital lists. A cheaper policy might give you access to a local network of private hospitals, while a more expensive one will provide a nationwide or even London-based list of premier facilities. Ensure the hospitals you'd want to use are on your list before you need them.
- Talk to an Expert Broker: A good broker does more than just sell a policy. At WeCovr, we help you compare the market to find the right cover for your needs and budget. We explain the small print and ensure you understand all the exclusions, so there are no nasty shocks down the line.
The WeCovr Advantage: More Than Just Insurance
We believe in providing holistic value that goes beyond the policy document. When you arrange your private health cover through WeCovr, you get more than just peace of mind.
- Complimentary Access to CalorieHero: All our health and life insurance clients receive free access to our AI-powered calorie and nutrition tracking app, CalorieHero. It's a powerful tool to help you manage your diet and achieve your wellness goals.
- Multi-Policy Discounts: We value your loyalty. When you take out a PMI or life insurance policy with us, you become eligible for discounts on other types of cover you might need, from home to travel insurance.
- Expert, Unbiased Advice: As an independent, FCA-authorised broker, our priority is you. We are not tied to any single insurer. Our goal is to find the best private medical insurance UK has to offer for your specific situation, saving you time and money while ensuring you have the right protection. Our high customer satisfaction ratings reflect our commitment to this principle.
Wellness & Lifestyle: Reducing Your Need to Claim
The best claim is the one you never have to make. While PMI is an essential safety net, investing in your health is the best policy of all.
- Balanced Diet: Follow the principles of the NHS Eatwell Guide. Aim for a diet rich in fruits, vegetables, whole grains, and lean proteins while limiting processed foods, sugar, and saturated fats.
- Regular Exercise: The NHS recommends at least 150 minutes of moderate-intensity activity (like brisk walking or cycling) or 75 minutes of vigorous-intensity activity (like running or swimming) per week, plus strength exercises on two or more days.
- Quality Sleep: Aim for 7-9 hours of quality sleep per night. It's vital for physical repair, mental health, and immune function. Create a relaxing bedtime routine and a dark, quiet, and cool sleeping environment.
- Mental Wellbeing: Make time for activities that reduce stress, such as mindfulness, yoga, spending time in nature, or connecting with friends and family. Don't be afraid to talk about your mental health.
Taking proactive steps to manage your health can reduce your risk of developing many acute and chronic conditions, helping you live a longer, healthier life.
Does private health insurance cover pre-existing conditions at all?
Will my premiums go up if I make a claim?
Is mental health treatment ever covered by UK private medical insurance?
Navigating the world of private health insurance exclusions can feel complex, but it doesn't have to be. With the right knowledge and expert guidance, you can choose a policy that provides genuine peace of mind and value.
Ready to find the right private health cover for you?
Sources
- Department for Transport (DfT): Road safety and transport statistics.
- DVLA / DVSA: UK vehicle and driving regulatory guidance.
- Association of British Insurers (ABI): Motor insurance market and claims publications.
- Financial Conduct Authority (FCA): Insurance conduct and consumer information guidance.
